Small Business Health Options Program (SHOP)

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1 Small Business Health Options Program (SHOP) Application for employees Complete this application to apply for SHOP health coverage from your employer. Go online Visit CoveredCA.com. You ll be able to see details about Covered California s SHOP Health Insurance Marketplace. THINGS TO KNOW Get help What happens next? Alternatives Ask your employer who to call with questions Online: CoveredCA.com Phone: Call our Service Center at (877) En Español: Llame a nuestro centro de ayuda gratis al (877) You ll return your completed, signed application to your employer. Your employer will send us your completed, signed application. If your share of the cost of employee-only coverage is more than 9.5% of your household income, you may able to get help paying for coverage through Covered California s individual marketplace. Visit CoveredCA.com to learn more. Your information is private. We ll keep your information private as required by law. Your answers on this application will only be used to see if you qualify and to enroll you in health coverage in SHOP. California Certified Insurance Agent with questions, visit CoveredCA.com or call us at (877) Para obtener una copia de este formulario en Español, llame (877)

2 Who is your employer? Employer name & address Employer phone number ( ) Not interested in SHOP health coverage? If you don t want SHOP health coverage from your employer, skip to Step 6 on page 4. STEP 1 I m interested in SHOP insurance from this employer. Information about you, the employee. 1. First name, Middle name, Last name, & Suffix 2. Social Security Number or Tax ID Number 3. Date of birth (mm/dd/yyyy) 4. Home address 5. Apartment or suite number 6. City 7. State 8. ZIP code 9. County 10. Mailing address (if different from home address) 11. Apartment or suite number 12 City 13. State 14. ZIP code 15. County 16. address (OPTIONAL) 17. Phone number Cell Home Work 18. Other phone number Cell ( ) ( ) 19. Cal-COBRA/COBRA Applicants: Cal-COBRA COBRA 20. For CalCOBRA/COBRA applicants, indicate qualifying event : Termination of employment Death of employee Cal-COBRA/COBRA effective date: (Cal-COBRA applicants must submit first month s premium) Reduction of hours Child no longer eligible Divorce/Legal separation Medicare entitlement 21. Marital Status: Single Married Domestic Partnership (DP) Date of Qualifying Event: 22. Preferred spoken or written language (OPTIONAL if not English) Home Work 23. What is the preferred method of communication? Mail Phone Tell us about your race Please tell us about yourself. This information is confidential and will only be used to make sure that everyone has the same access to health care. It will not be used to decide what health insurance you qualify for. 24. Are you of Hispanic/Latino, or Spanish origin? (OPTIONAL) Yes No If yes, check which one(s): Mexican, Mexican American, Chicano Salvadoran Puerto Rican Cuban Guatemalan 25. Race (OPTIONAL Check all that apply.) White American Indian or Black or African Alaska Native American Asian Indian Cambodian Chinese Filipino Hmong Japanese Korean Laotian Vietnamese Native Hawaiian 26. If you re American Indian or Alaska Native, tell us the state and the name of your federally-recognized tribe (optional): Other Hispanic, Latino or Spanish origin: Guamanian or Chamorro Samoan Other Page 1 of 4

3 STEP 2 Please tell us about yourself and your eligible enrolling dependents and indicate your SHOP Health Insurance plan selection. California law defines a dependent for health care coverage in the following way: Dependent means the spouse or registered domestic partner, or child, of an eligible employee, subject to applicable terms of the health care service plan contract covering the employee, and includes dependents of guaranteed association members if the association elects to include dependents under its health coverage at the same time it determines its membership composition. EMPLOYEE NAME OF HEALTH PLAN SELECTED SPOUSE OR DOMESTIC PARTNER ARE YOU A DOMESTIC PARTNER? Y / N IF YES, IS YOUR PARTNERSHIP REGISTERED WITH THE STATE OF CALIFORNIA? Y / N IS BOTH DISABLED IS BOTH DISABLED IS BOTH DISABLED *Can be found in your selected plans provider directory. My employer does not offer dependent coverage and I am interested in information on how I can obtain other coverage for my dependents. I wish to have someone contact me to help me understand my options. Page 2 of 4

4 STEP 3 Covered California arbitration agreement I understand that, if I select a Health Plan that uses mandatory binding arbitration to resolve disputes, I am agreeing to arbitrate claims that relate to my or a dependent's membership in the Health Plan (except for Small Claims Court cases and claims that cannot be subject to binding arbitration under governing law). I understand that any dispute between myself, my heirs, relatives, or other associated parties on the one hand and the Health Plan, any contracted health care providers, administrators, or other associated parties on the other hand for alleged violation of any duty arising out of or related to membership in the Health Plan, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is in the Health Plan s coverage document, which is available for my review. Signature of Applicant (or financially-responsible party if Applicant is under the age of 18) Print Name STEP 4 If a Certified Insurance Agent helped you complete this application, please obtain their signature below. I did not use a Certified Insurance Agent. The applicant completed and executed this application, and I assisted the applicant by offering advice in providing responses to questions. I advised the applicant that he/she should answer all such questions completely and truthfully and that no information requested should be withheld. I explained to the applicant, in easy-to-understand language, the risk to the applicant of providing inaccurate information and the applicant understood the explanation. To the best of my knowledge, based on what the applicant disclosed to me, the information in this application is accurate and complete. I understand that if any portion of this statement signed by me is false, I may be subject to civil penalties of up to $10,000 as authorized under California Health and Safety Code Section and Insurance Code Section Signature of Certified Insurance Agent Print Name Date STEP 5 Read & sign this application. I am signing this application under penalty of perjury, which means I ve provided true answers to all of the questions to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information. I know that my information on this form will only be used to determine eligibility for health coverage and will be kept private as required by law. If I m eligible, it will be used to help me enroll. I know that I must tell SHOP if anything changes from what I wrote on this application. I can call my employer, my employer s Covered California Certified Insurance Agent or call (877) to report changes. I know that under federal law, discrimination isn t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting Signature of Applicant Page 3 of 4

5 STEP 6 Complete this section if you are declining coverage from your employer for you or your dependents. I am declining coverage for (check all that apply): Self Spouse/Domestic Partner Child(ren) Reason for declining coverage: Covered by spouse s/domestic partner s group plan Covered by Medicare Covered by individual policy Covered by Medi-Cal Covered by Tricare Covered by other: Coverage is too expensive. (You may be eligible for a Federal subsidy through the Covered California Individual Marketplace.) List names of all dependents declining coverage: Employee name Signature of Employee STEP 7 Return your completed, signed application to your employer. Your employer will send us your application, and we will contact you if we need additional information or to let you know you have been approved for coverage. If you are not registered to vote where you live now and would like to apply to register to vote today please visit registertovote.ca.gov or call VOTE (8683). Page 4 of 4

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